Psychotherapy with individual

Learning Objectives

Students will:

• Assess progress for clients receiving psychotherapy


• Differentiate progress notes from privileged notes


• Analyze preceptor’s use of privileged notes

To prepare:

• Reflect on the client you selected for the Week 3 Practicum Assignment. 


• Review the Cameron and Turtle-Song (2002) article in this week’s  Learning Resources for guidance on writing case notes using the SOAP  format.

The Assignment

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

• Treatment modality used and efficacy of approach 


• Progress and/or lack of progress toward the mutually agreed-upon  client goals (reference the Treatment plan—progress toward goals)


• Modification(s) of the treatment plan that were made based on progress/lack of progress


• Clinical impressions regarding diagnosis and/or symptoms


• Relevant psychosocial information or changes from original  assessment (i.e., marriage, separation/divorce, new relationships, move  to a new house/apartment, change of job, etc.)


• Safety issues 


• Clinical emergencies/actions taken 


• Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)


• Treatment compliance/lack of compliance


• Clinical consultations


• Collaboration with other professionals (i.e., phone consultations  with physicians, psychiatrists, marriage/family therapists, etc.)


• Therapist’s recommendations, including whether the client agreed to the recommendations


• Referrals made/reasons for making referrals 


• Termination/issues that are relevant to the termination process  (i.e., client informed of loss of insurance or refusal of insurance  company to pay for continued sessions)


• Issues related to consent and/or informed consent for treatment 


• Information concerning child abuse, and/or elder or dependent adult  abuse, including documentation as to where the abuse was reported


• Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

 

Part 2: Privileged Note

Based  on this week’s readings, prepare a privileged psychotherapy note that  you would use to document your impressions of therapeutic  progress/therapy sessions for your client from the Week 3 Practicum  Assignment.

• The privileged note should include items that you would not typically include in a note as part of the clinical record. 


• Explain why the items you included in the privileged note would not be included in the client’s progress note.


• Explain whether your preceptor uses privileged notes, and if so,  describe the type of information he or she might include. If not,  explain why.